SEC Form 4 · accession 0000731012-17-000012
HEALTHCARE SERVICES GROUP INC · HCSG
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Theodore Wahl
Officer — President & CEO · Director
Period of report
Dec 31, 2016
Accepted (ET)
Jan 4, 2017 · 8:31 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000731012
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1,F2 | Dec 31, 2016 | A | 715 | $29.64 | A | 110,111 | D | |
| Common StockF2 | holding | — | — | — | 84,536 | I | Held by spouse | |
| Common StockF2 | holding | — | — | — | 28,418 | I | Held by minor child |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Stock Option (right to buy)F3 | $39.38 | Jan 4, 2017 | A | 30,000 | A | Jan 4, 2022 | Jan 4, 2027 | Common Stock | 30,000 | 30,000 | D |
| Restricted Stock UnitsF4,F5 | — | Jan 4, 2017 | A | 30,000 | A | Jan 4, 2022 | — | Common Stock | 30,000 | 30,000 | D |
| Phantom StockF6,F4,F7 | — | Dec 31, 2016 | A | 963 | A | Dec 31, 2016 | — | Common Stock | 963 | 963 | D |
Explanation of responses
- F1Acquired by the Reporting Person through participation in the Healthcare Services Group, Inc. Employee Stock Purchase Plan
- F2Total Direct and Indirect Beneficial Ownership by Reporting Person is 223,065 shares.
- F3These options shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
- F4Shares issued at the conversion rate of 1-for-1.
- F5These Restricted Stock Units shall vest and become exercisable at the rate of 20% annually, commencing on the first anniversary of the January 4, 2017 grant date.
- F6Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan.
- F7Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer.